SLR - May 2010 - Jonathan Deming

Foot Kinematics During a Bilateral Heel Rise Test in Participants With Stage II Posterior Tibial Tendon Dysfunction

Houck, J., Neville, C., Tome, J., Flemister, A. (2009).  Foot kinematics during a bilateral heel rise test in participants with stage-II posterior tibial tendon dysfunction.  Journal of Orthopaedic & Sports Physical Therapy, 39(8), 593-603.

Scientific Literature Reviews

Reviewed by:  Jonathan Deming, DPM
Residency Program: St. John Hospital and Medical Center; Detroit, MI.

Podiatric Relevance:
This study investigates the clinical relevance of the heel rise test in evaluating patients with posterior tibialis tendon dysfunction (PTTD).  It compares the kinematics of the forefoot and rearfoot in all planes of motion in patients with stage II PTTD versus patients with no foot pathology.  Medial longitudinal arch (MLA) height is evaluated as well.  This research poses the question of which is more relevant when assessing posterior tibial tendon function: calcaneal inversion or first ray sagittal plane kinematics? 

Thirty participants with unilateral stage II PTTD and 15 control subjects with no history of foot or ankle problems were evaluated.  All participants were informed of the study and comparisons were made between the 2 groups.  PTTD was clinically diagnosed by an orthopedic surgeon as stage II and subjects with foot pain preventing them from ambulating >15m were excluded.  MLA was measured as a ratio of dorsum height at 50% of foot length divided by foot length from heel to toe.  STJ neutral position was established and first metatarsal declination angle was normalized using techniques described in prior studies to account for variation in foot structure.  Infrared markers were placed on anatomical landmarks and participants were asked to perform a series of heel rises on both feet.  Variables compared included calcaneal inversion/eversion, ankle plantar/dorsi flexion, first metatarsal plantar/dorsi flexion and hallux plantar/dorsi flexion.  Total ROM was also compared as a secondary hypothesis.

Sagittal plane kinematics were significantly different between the PTTD group and control.  PTTD used greater ankle plantar flexion, greater first metatarsal dorsiflexion and less hallux dorsiflexion with heel rise.  Fifty percent of the PTTD patients failed to reach plantar flexion at the first metatarsal compared to 100% of the control.  Calcaneal inversion/eversion depended on both the group and the phase of the heel rise cycle.  At peak heel rise the amounts of inversion were similar between groups, however ROM was significantly decreased with inversion of the heel within the PTTD group.  Seven of 30 patients of the PTTD group failed to invert while only 1 of 15 in the control group failed to invert (not a statistically significant difference).

Individuals with stage II PTTD are more likely to display abnormal first ray dorsiflexion than the inability to invert the calcaneus upon 2 foot heel rise.  The amount of motion that took place was similar between groups suggesting that MLA raising and lowering occurred in both groups, however over a different range of joint movements.  The implication of this study would be that perhaps MLA kinematics are more sensitive in identifying abnormal foot movement in stage II PTTD.

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